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Environmental Health Services Division <br />Marion County Department of Public Health <br />Salem, Oregon 9730i (588-$346), agent ior: <br />Departm~ent of Environmental Quality <br /> <br />To be submitted with application for <br />building permit or mobile home place- <br />merit permit. <br /> <br />Application to the Department of Environmental Quality <br /> for a Permit to Construct a New er <br /> a Subsurface Sewage Disposal System <br /> <br />Permit Fees: Ne__w- $75.00 ($37.50 with site evaluation) <br /> <br />~, Re~,~c~,~ Alteratio~ - $25.00 <br /> <br />REFER ~NCm INFORMATION <br /> Dwight Neber <br /> <br />Name o£ Applicant <br /> <br />Section 21 Twp 4 Rge ]w <br /> <br />PO Box 350~ <br />Mailing Addresa <br /> <br />PortlandxRRxx Or. 97~208 <br />City, State, Zip Code <br /> <br />Tax Lot or Acceunt # 4~0857-001 <br /> <br />Lot Size <br /> <br /> Rt. I Re× 248 D'R Aurora <br /> <br />Site Evaluation-~'eriaI Number <br /> <br />Insta]ler'~ Name <br /> <br />Ne::w Const'ruction~. x .... Repair <br /> <br />Installation will serve: He~.}se Mobile Home Mobile Home Park <br /> <br />Commercial Building .... Other (explain) .... <br />Number of Living Units 2 ~umberiof Bedrooms 2 + 3= c~ ~ <br /> <br />Water Sepply: Public ..... Co~sunity ~, Private x Garbage Disposal? ,, no ,. <br /> <br />t. Proposed Subsurface Sewage Disposal System Plot Plan <br /> <br />2. Planning Evaluation -- Building Permit <br /> <br />3. Bu;ilding Plans <br /> <br />I. hereby certify that the information contained in tJ~s application is true and correct <br />t:o the bast of my knowledge., and belief. <br /> <br />Issued e>-- ' ~ <br /> <br /> <br />